Appropriateness of Empirical Antibiotic Therapy for Cervicitis and Urethritis Prescribed in the Emergency Department.

Objectives: Sexually transmitted infections are a prevalent global health care problem. Treatment guidelines have recently been updated as a result of antimicrobial resistance and public health trends. The aim of the study was to assess the appropriateness of empirical antibiotic therapy prescribed for cervicitis and urethritis in the emergency department. Methods: We designed a retrospective observational cohort study. We included adult patients with suspected cervicitis or urethritis who attended the emergency department of a tertiary hospital in 2020. We excluded patients with suspected pelvic inflammatory disease, pregnancy or prostatitis and those requiring admission to hospital. Appropriateness of empirical antibiotic therapy was evaluated taking into account 4 aspects: indication, dosing, duration of therapy, and route of administration. Data were obtained from the electronic medical record, the electronic prescription program, and the discharge summary. Results: The study population comprised 176 patients; mean age was 28.9 years (SD = 7.7), and 90.9% were men. The most prescribed treatment was the combination of ceftriaxone and azithromycin (83.0%). Treatment was inappropriate in 71.6% of patients. A total of 159 drug errors were recorded. The most frequent cause was undertreatment (36.4%) related to underdosing (46.5%), particularly with regard to ceftriaxone. The percentage of errors was 11.9% for indication, 84.9% for dosing, 3.1% for duration, and 0% for route of administration. Conclusions: A high percentage of patients who attended the emergency department for suspected cervicitis or urethritis received an inappropriate empirical antibiotic regimen. The main reason was undertreatment due to underdosing.

Mobile Health Apps Providing Information on Drugs for Adult Emergency Care: Systematic Search on App Stores and Content Analysis.

BACKGROUND: Drug-referencing apps are among the most frequently used by emergency health professionals. To date, no study has analyzed the quantity and quality of apps that provide information on emergency drugs. OBJECTIVE: This study aimed to identify apps designed to assist emergency professionals in managing drugs and to describe and analyze their characteristics. METHODS: We performed an observational, cross-sectional, descriptive study of apps that provide information on drugs for adult emergency care. The iOS and Android platforms were searched in February 2021. The apps were independently evaluated by 2 hospital clinical pharmacists. We analyzed developer affiliation, cost, updates, user ratings, and number of downloads. We also evaluated the main topic (emergency drugs or emergency medicine), the number of drugs described, the inclusion of bibliographic references, and the presence of the following drug information: commercial presentations, usual dosage, dose adjustment for renal failure, mechanism of action, therapeutic indications, contraindications, interactions with other medicinal products, use in pregnancy and breastfeeding, adverse reactions, method of preparation and administration, stability data, incompatibilities, identification of high-alert medications, positioning in treatment algorithms, information about medication reconciliation, and cost. RESULTS: Overall, 49 apps were identified. Of these 49 apps, 32 (65%) were found on both digital platforms; 11 (22%) were available only for Android, and 6 (12%) were available only for iOS. In total, 41% (20/49) of the apps required payment (ranging from €0.59 [US $0.64] to €179.99 [US $196.10]) and 22% (11/49) of the apps were developed by non-health care professionals. The mean weighted user rating was 4.023 of 5 (SD 0.71). Overall, 45% (22/49) of the apps focused on emergency drugs, and 55% (27/49) focused on emergency medicine. More than half (29/47, 62%) did not include bibliographic references or had not been updated for more than a year (29/49, 59%). The median number of drugs was 66 (range 4 to >5000). Contraindications (26/47, 55%) and adverse reactions (24/47, 51%) were found in only half of the apps. Less than half of the apps addressed dose adjustment for renal failure (15/47, 32%), interactions (10/47, 21%), and use during pregnancy and breastfeeding (15/47, 32%). Only 6% (3/47) identified high-alert medications, and 2% (1/47) included information about medication reconciliation. Health-related developer, main topic, and greater amount of drug information were not statistically associated with higher user ratings (P=.99, P=.09, and P=.31, respectively). CONCLUSIONS: We provide a comprehensive review of apps with information on emergency drugs for adults. Information on authorship, drug characteristics, and bibliographic references is frequently scarce; therefore, we propose recommendations to consider when developing an app of these characteristics. Future efforts should be made to increase the regulation of drug-referencing apps and to conduct a more frequent and documented review of their clinical content.

Comparison of a polypharmacy-based scale with Charlson comorbidity index to predict 6-month mortality in chronic complex patients after an ED visit.

AIMS: The aim of this study was to test whether a newly designed polypharmacy-based scale would perform better than Charlson's Comorbidity Index (CCI) to predict outcomes in chronic complex adult patients after a reference Emergency Department (ED) visit. METHODS: We built a polypharmacy-based scale with prespecified drug families. The primary outcome was 6-month mortality after the reference ED visit. Predefined secondary outcomes were need for hospital admission, 30-day readmission, and 30-day and 90-day mortality. We evaluated the ability of the CCI and the polypharmacy-based scale to independently predict 6-month mortality using logistic regression, receiver operating characteristic (ROC) curves, and cumulative survival curves using Kaplan-Meier estimates and the log-rank test for three-category distributions of the polypharmacy-based scale and the CCI. Finally, we sought to replicate our results in two different external validation cohorts. RESULTS: We included 201 patients (53.7% women, mean age = 81.4 years), 162 of whom were admitted to the hospital at the reference ED visit. In separate multivariable analyses accounting for gender, age and main diagnosis at discharge, both the polypharmacy-based scale (P < .001) and the CCI (P = .005) independently predicted 6-month mortality. The polypharmacy-based scale performed better in the ROC analyses (area under the curve [AUC] = 0.838, 95% confidence interval [CI] = 0.780-0.896) than the CCI (AUC = 0.628, 95% CI = 0.548-0.707). In the 6-month cumulative survival analysis, the polypharmacy-based scale showed statistical significance (P < .001), whereas the CCI did not (P = .484). We replicated our results in the validation cohorts. CONCLUSIONS: Our polypharmacy-based scale performed significantly better than the CCI to predict 6-month mortality in chronic complex patients after a reference ED visit.

[Quality control of parenteral nutrition compounding: gravimetric and component verification control]. / Control de calidad de la elaboración de nutriciones parenterales: control gravimétrico y de productos utilizados.

INTRODUCTION: Introduction: parenteral nutrition (PN) compounding is a process with a high probability of errors. Objective: to analyze PN compounding errors detected using a gravimetric control (GC) and a component verification control (CVC). Methods: a prospective analysis was carried out during a three-year period (January 2016 to December 2018). The MedicalOne Parenteral® software program was used to calculate the theoretical weight of each PN based on density and volume. Each elaborated PN was weighed to obtain the real weight. Gravimetric error (%) ((real weight - theoretical weight) x 100 / theoretical weight) was considered correct if within the ± 5 % interval. The CVC consisted of checking that the correct ingredients and volumes were added according to the PN order. Results: during the study period a total number of 28,761 PNs were checked out; 20,612 adult PNs (APN) were weighed and 124 were considered incorrect (0.60 %). Of the 1,203 non-neonatal pediatric PNs (NPPN), 15 (1.25 %) were incorrect, and of the 6,946 neonatal PNs (NPN), 164 (2.96 %) were incorrect. Regarding the CVC, 71 errors were detected in the APN (0.70 %), 6 (1.34 %) in the NPPN, and 5 (0.21 %) in the NPN group. The total number of errors included: adding more volume of one component [38 (46.34 %)], adding a wrong component [27 (32.93 %)], and absent volume of one component [17 (20.73 %)]. Conclusions: the quality control carried out allowed to detect errors during the preparation of PNs and prevented them from reaching the patient. More incorrect NPNs were detected through GC. The main error detected with CVC was adding more volume of a component.

INTRODUCCIÓN: Introducción: la elaboración de nutriciones parenterales (NP) es un proceso complejo y con alta probabilidad de aparición de errores. Objetivo: analizar los errores detectados en el control gravimétrico (CG) y de productos (CP) utilizados realizado en las NP elaboradas. Métodos: se realizó un análisis prospectivo en el que durante tres años (enero de 2016 a diciembre de 2018) se pesaron las NP elaboradas. Se utilizó el programa informático MedicalOne Parenteral®, que calcula el peso teórico teniendo en cuenta la densidad y el volumen. Cada NP elaborada se pesaba para obtener el peso real. El error gravimétrico (%) (EG = (peso real - peso teórico) x 100 / peso teórico) se consideró correcto dentro del intervalo de ± 5 %. El CP consistía en la comprobación de los productos y los volúmenes utilizados con la hoja de elaboración. Resultados: se realizó el control de 28.761 NP. Se pesaron 20.612 NP de adultos (NPA), siendo incorrectas 124 (0,6 %). De las 1203 NP de pacientes pediátricos no neonatos (NPP), 15 (1,25 %) fueron incorrectas, y de las 6946 de neonatos (NPN), 164 (2,96 %). Respecto al CP se detectaron 71 errores en las NPA (0,70 %), 6 (1,34 %) en las NPP y 5 (0,21 %) en las NPN. Los errores fueron: añadir más volumen de un componente [38 (46,34 %)], añadir menos volumen [17(20,73 %)] y producto erróneo [27 (32,93 %)]. Conclusiones: el control de calidad realizado permitió detectar errores producidos durante la elaboración y evitó que llegaran al paciente. Se detectaron en el CG más NP incorrectas entre las NPN. Con el CP, el error mayoritario fue añadir más volumen de un componente.

Effectiveness, Safety, and Costs of Dolutegravir/Abacavir/Lamivudine Single-Tablet Regimen in a Real-Life Cohort of HIV-1 Adult Infected Patients.

Background: Real-life data on single-tablet regimen (STR) dolutegravir/abacavir/lamivudine (DTG/ABC/3TC) is scarce, and concerns about DTG neuropsychiatric adverse events (NP-AEs) have recently arisen. Objective: To explore the effectiveness and safety, in particular NP-AEs, of DTG/ABC/3TC in a cohort of HIV-1 adult infected patients. Pill burden, adherence to this STR, and the impact of switching on costs were also evaluated. Methods: This was an observational, retrospective study. The study population included antiretroviral therapy (ART)-naive and treatment-experienced (TE) patients who started DTG/ABC/3TC between February 1, 2016, and October 31, 2016. Effectiveness and safety were analyzed at week 48 (W48) by intention-to-treat analysis. The Cox regression model was used to investigate predictors of DTG/ABC/3TC discontinuation. Results: A total of 253 patients were included (44 ART naïve, 209 TE). At W48, the proportion of patients with virological suppression was 72.7% (95% CI = 58.4-87.0) in ART-naive patients, 85.6% (95% CI = 80.3-90.9) in previously suppressed TE patients, and 86.4% (95% CI = 65.1-97.1) in previously not suppressed TE patients. The rate of protocol-defined virological failure was 4.3%. The incidence of AEs was higher in the subgroup of ART-naive patients (56.1% vs 39.0%), with a rate of interruptions for this reason of 13.6% and 7.6%, respectively. The incidence of NP-AEs was 20.6%, with 3.9% of patients requiring discontinuation. Patients who had switched from a raltegravir-containing regimen discontinued DTG/ABC/3TC because of AEs more frequently (relative risk = 2.83; 95% CI = 1.04-7.72; P = 0.041) in the multivariate analysis. After switching to DTG/ABC/3TC, the median pill burden was reduced from 3 to 1 and the proportion of patients with an adherence <90%, from 20.1% to 12.0%. The annual per-patient ART costs increased by €48 (0.6% increase). Conclusion and Relevance: DTG/ABC/3TC is an effective strategy as first-line and switching ART. Our data suggest a worse tolerance in ART-naive patients, although the rate of discontinuation resulting from NP-AEs was relatively low. In the short-term, the adherence was slightly improved without significant changes in costs.

Drug safety surveillance within a strategy for the management of non-chemotherapy drug-induced neutropenia.

Background Severe non-chemotherapy drug-induced neutropenia is a rare idiosyncratic drug reaction that is considered potentially fatal. Objective To report, in terms of drug safety surveillance, the results of an institutional strategy for NCDIN. Method An observational and prospective study including all adult patients who received filgrastim for the treatment of NCDIN from June 2015 to December 2017 was carried out by hematologists and clinical pharmacists. Results 13 patients with severe NCDIN were included in the study. The median age was 51 (range 24-80) years old and 46.2% were male. Seven patients had one or more negative prognostic factors (age > 65 years, renal impairment, autoimmune diseases and/or a neutrophil count at diagnosis < 0.1 × 109 cells/L). A single drug was identified as causative in 3 patients, while in 10 cases, 2-3 drugs were considered as potentially causative. The most frequent drugs were metamizole, piperacillin/tazobactam, dexketoprofen and linezolid, among others. Seven patients developed NCDIN during their hospital stay while 6 were admitted to the emergency department. Patients were using a median of 11 drugs (IQR 8-15) at the time of diagnosis. No deaths were recorded. Conclusion Metamizole and piperacillin/tazobactam are the most common drugs linked to non-chemotherapy drug-induced neutropenia in our cohort.

Trends in hospital consumption of analgesics after the implementation of a pain performance improvement plan / Tendências no consumo hospitalar de analgésicos após a implantação de plano de melhoria do controle da dor

Abstract Background: Pain management committee established a pain performance improvement plan in 2012. Objectives: The aim of the study was to assess the trends in analgesic consumption in a tertiary teaching hospital and the associated economic impact. Methods: A descriptive, retrospective study was conducted between 2011 and 2015. The analysis included: anti-inflammatory and antirheumatic products non-steroids, opioid analgesics and other analgesics and antipyretics. Data are converted into DDD/100 bed-days to analyze consumption trends. Main outcome measure: assessment of the analgesic consumption after the implementation of a pain performance improvement plan. Results: Overall, non-steroidal anti-inflammatory and antirheumatic products consumption decreased in 24.8 DDD/100 bed-days (-28.3%), accounting for most of the total analgesic consumption decrease (-13%) and total cost (-44.3%). Opioid consumption increased markedly from 22.3 DDD/100 bed-days in 2011 to 26.5 DDD/100 bed-days in 2015 (+18.9%). In 2011, the most consumed opioid was morphine (8.6 DDD/100 bed-days). However, there was an increasing trend in fentanyl consumption (from 8.1 to 12.1 DDD/100 bed-days in 2015), which resulted in fentanyl replacing morphine from the most consumed opioid in 2015 (12.1 DDD/100 bed-days). In 2015, the group of other analgesics and antipyretics represented 46.2% of the total analgesic consumption. Acetaminophen was the most commonly consumed analgesic drug (53.2 DDD/100 bed-days in 2015) and had the highest total cost, it represented 55.4% of the overall cost in 2015. Conclusion: Opioid consumption showed an increasing trend during the 5 year period, with fentanyl replacing morphine as the most used opioid. In general, analgesics diminished use was due to the decreasing trend of consumption of non-steroidal anti-inflammatory and antirheumatic products.

Resumo Justificativa: A Comissão para o Manejo da Dor estabeleceu um plano de melhoria no controle da dor em 2012. Objetivo: Avaliar as tendências do consumo de analgésicos em um hospital de ensino terciário e o impacto econômico associado. Métodos: Estudo descritivo, retrospectivo, feito entre 2011 e 2015. A análise incluiu: produtos anti-inflamatórios e antirreumáticos não esteroides, analgésicos opioides e outros analgésicos e antipiréticos. Os dados foram convertidos em DDD/100 leitos-dia para analisar as tendências de consumo. Principal medida do desfecho: avaliação do consumo de analgésicos após o estabelecimento de um plano de melhoria no controle da dor. Resultados: O consumo total de produtos anti-inflamatórios e antirreumáticos não esteroides diminuiu em 24,8 DDD/100 leitos-dia (-28,3%), representando a maior parte da redução total do consumo de analgésicos (-13%) e o custo total (-44,3%). O consumo global de opioides aumentou acentuadamente de 22,3 DDD/100 leitos-dia em 2011 para 26,5 DDD/100 leitos-dia em 2015 (+18,9%). Em 2011, o opioide mais consumido foi a morfina (8,6 DDD/100 leitos-dia). No entanto, houve uma tendência crescente no consumo de fentanil (de 8,1 para 12,1 DDD/100 leitos-dia em 2015), o que resultou na substituição de morfina por fentanil como o opioide mais consumido em 2015 (12,1 DDD/100 leitos-dia). Em 2015, o grupo dos outros analgésicos e antipiréticos representou 46,2% do consumo total de analgésicos. Acetaminofeno foi o analgésico mais consumido (53,2 DDD/100 leitos-dia em 2015) e teve o maior custo total, representou 55,4% do custo total em 2015. Conclusão: O consumo de opioides mostrou uma tendência crescente durante o período de cinco anos, fentanil substituiu morfina como o opioide mais usado. Em geral, o uso diminuído de analgésicos foi devido à tendência decrescente do consumo de produtos anti-inflamatórios e antirreumáticos não esteroides.

[Trends in hospital consumption of analgesics after the implementation of a pain performance improvement plan]. / Tendências no consumo hospitalar de analgésicos após a implantação de plano de melhoria do controle da dor.

BACKGROUND: Pain management committee established a pain performance improvement plan in 2012. OBJECTIVE: The aim of the study was to assess the trends in analgesic consumption in a tertiary teaching hospital and the associated economic impact. METHODS: A descriptive, retrospective study was conducted between 2011 and 2015. The analysis included: anti-inflammatory and antirheumatic products non-steroids, opioid analgesics and other analgesics and antipyretics. Data are converted into DDD/100 bed-days to analyze consumption trends. MAIN OUTCOME MEASURE: assessment of the analgesic consumption after the implementation of a pain performance improvement plan. RESULTS: Overall, non-steroidal anti-inflammatory and antirheumatic products consumption decreased in 24.8 DDD/100 bed-days (-28.3%), accounting for most of the total analgesic consumption decrease (-13%) and total cost (-44.3%). Opioid consumption increased markedly from 22.3 DDD/100 bed-days in 2011 to 26.5 DDD/100 bed-days in 2015 (+18.9%). In 2011, the most consumed opioid was morphine (8.6 DDD/100 bed-days). However, there was an increasing trend in fentanyl consumption (from 8.1 to 12.1 DDD/100 bed-days in 2015), which resulted in fentanyl replacing morphine from the most consumed opioid in 2015 (12.1 DDD/100 bed-days). In 2015, the group of other analgesics and antipyretics represented 46.2% of the total analgesic consumption. Acetaminophen was the most commonly consumed analgesic drug (53.2 DDD/100 bed-days in 2015) and had the highest total cost, it represented 55.4% of the overall cost in 2015. CONCLUSION: Opioid consumption showed an increasing trend during the 5 year period, with fentanyl replacing morphine as the most used opioid. In general, analgesics diminished use was due to the decreasing trend of consumption of non-steroidal anti-inflammatory and antirheumatic products.

Cancellations of elective surgical procedures due to inadequate management of chronic medications.

WHAT IS KNOWN AND OBJECTIVES: Inadequate management of chronic medication puts patients at risk and causes unnecessary suspension of surgical procedures. The objective of the study was to calculate the rate of cancellation of elective surgical procedures due to inadequate management of chronic medications and to analyse the underlying causes of cancellation. METHODS: We designed an analytic, observational, retrospective study of all elective surgical procedures performed from July to October 2017 in a tertiary hospital. The main variable was the percentage of surgeries cancelled owing to inadequate management of chronic medications. Other variables recorded included demographic characteristics, time between the preanaesthesia evaluation and surgery, drug involved, and the reason for incorrect management of the medication. RESULTS: During the study period, 5415 surgical procedures were programmed, and 793 (14.6%) were cancelled. Cancellations due to inadequate patient preparation accounted for 5.3% (42 cases), and 19 were related to incorrect medication management (2.4% of the total number of cancellations). The 19 patients, who were mostly men (73.7%), had a median age of 76 years (IQR 68-81). The drugs involved were acenocoumarol (6), enoxaparin (4), clopidogrel (4), direct-acting oral anticoagulants (2), acetylsalicylic acid (1), tocilizumab (1) and leflunomide (1). The reasons for drug mishandling were poor understanding of the anaesthesiology recommendations (15) and lack of a preanaesthesia evaluation (4). WHAT IS NEW AND CONCLUSION: Inadequate management of chronic medications (2.4%) is not the most frequent reason for cancellation, although it is one of the easiest to avoid. Based on our results, starting in October 2017, the Pharmacy Department began to offer a pharmaceutical service to patients with doubts about the preoperative management of chronic medications.

Polypharmacy and enteral nutrition in patients with complex chronic diseases / La polifarmacia del paciente crónico complejo y la nutrición enteral.

Oral medications are often administered through enteral feeding tubes in patients with complex chronic diseases. It is important to consider possible interactions between drugs and enteral nutrition that might lead to unsuccessful treatment or tube occlusion. These patients become subjects for higher risk of problems and errors such as drug incompatibility with enteral nutrition and inappropriate dosage form selection. It is possible to minimize the risk of tube occlusion and incompatibilities problems by recognizing potential medication errors, selecting the most appropriate drug and dosage form and using appropriate administration techniques. In this context, high-alert medications for patients with chronic diseases deserve special attention. Furthermore, risk exposure should be considered among healthcare professionals and patient caregivers handling hazardous drugs. Therefore, main incompatibility problems between drugs and enteral nutrition have been reviewed, including general recommendations for administration of oral medications through enteral feeding tubes and safe handling of hazardous drugs. Specific recommendations for administration of high-alert medications for patients with chronic diseases are also included.